Patients, Physicians Struggle With Part D Rollout


As Medicare beneficiaries grapple with the new prescription drug benefit that went into effect on Jan. 1, physicians report that they are spending valuable clinical time explaining the benefit, rewriting prescriptions, and navigating drug company Web sites.

“It's taking up a disproportionate amount of our time,” said Dr. Maurice Wright, medical director and staff internist of the So Others Might Eat Medical Clinic in Washington, a group that provides primary care services to needy patients, including Medicare beneficiaries.

Physicians weren't armed with the necessary information to properly advise patients about the new Medicare Part D benefit, Dr. Wright said.

And even after exploring the Medicare and drug plan Web sites, Dr. Wright said he still has unanswered questions about how to help his low-income Medicare patients apply for the “extra help” subsidy.

That low-income subsidy is especially important for his Medicare patients who do not qualify for Medicaid, he said. And without information about how to enroll, they can't choose a drug plan because they don't know how much it will cost, he said.

Dr. Wright has also noted problems among his patients who are dually eligible for Medicare and Medicaid. These patients were automatically enrolled in a Part D drug plan before the beginning of the year.

But some technical glitches in transmitting that enrollment information from Medicare to the drug plans means that for some patients there is either no record of their enrollment when they show up at the pharmacy or they are asked to pay higher prices.

Dual-eligible beneficiaries are also facing other problems as a result of automatic enrollment, Dr. Wright said.

For example, these patients may be signed up for plans that don't cover their medications. Alhough they can switch plans, figuring out the formulary list for the various plans can be difficult for patients, Dr. Wright said.

As of Jan. 13, the Department of Health and Human Services reported that 14.3 million Medicare beneficiaries have been enrolled in a Part D drug plan. The bulk of those enrolled—6.2 million—are beneficiaries who are dually eligible for Medicare and Medicaid and were assigned to Part D plans.

In addition, 4.5 million have enrolled in Medicare Advantage plans, which include drug coverage, and 3.6 million have signed up for stand-alone drug plans under Medicare.

AARP—which sponsors a prescription drug plan for AARP members—reports that overall the benefit implementation is going well. George Keleman, campaign manager for the AARP Medicare Rx Outreach Campaign, said the problems reported relate to communication systems between Medicare, the drug plans, and the pharmacies that have mainly affected dual-eligible beneficiaries.

Dr. Donna E. Sweet, an internist in Wichita, Kan., and chair of the board of regents for the American College of Physicians, has seen those problems firsthand in her practice. The biggest problem has been among her dual-eligible patients with AIDS who are on a three- or four-drug regimen that must be taken to keep from developing resistance. “They are leaving the pharmacy without medications,” she said.

The problem isn't that the drugs aren't covered by the participating drug plans but that the patient is either not in the system or is listed incorrectly and thus asked to pay a high copay or deductible.

Among her other patients, she's noticed that the very elderly—those aged 90 years and older—are opting out of the process entirely. For those patients who have selected a Medicare drug plan, Dr. Sweet has spent a lot of time reviewing medications and figuring out which ones can be switched to better correspond with the patient's formulary list. “It's a tremendous amount of staff and physician time,” she said.

But Dr. Sweet said that in the long run, the program will likely be an asset for most seniors.

Physicians can also expect to see a spike in the number of requests they receive for prior authorizations as a result of the Part D benefit, said Dr. Yul D. Ejnes, an internist in Cranston, R.I., and chair elect of the ACP board of governors.

Although most of the drugs requiring prior authorization are approved, Dr. Ejnes noted that prior authorization is being required by many plans for standard medications such as statin drugs or proton pump inhibitors.

He advised physicians to have patience and to make their patients aware that the plan they have selected requires this level of administrative hassle.

Many of his Medicare patients have also been receiving letters from their drug plan saying that the medication they have been prescribed is limited to a certain number of doses per month.


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